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Oregon Department of Revenue
5 Form OR-19-V 5
6 Tax for Pass-through Entity Owners Payment Voucher 6
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8 Page 1 of 1 • Use UPPERCASE letters. • Use blue or black ink. • Print actual size (100%). • Don’t submit photocopies or use staples. 8
9 Tax year begins (MM/DD/YYYY) Tax year ends (MM/DD/YYYY) 9
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11 99/99/9999/ / 99/99/9999/ / 11
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13 Contact first name Initial 13
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XXXXXXXXXXXXXXXX X
16 Contact last name 16
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
19 Pass-through entity (PTE) name 19
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
22 Federal employer identification number (FEIN) 22
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99-9999999
25 PTE address 25
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XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
28 City State ZIP code 28
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XXXXXXXXXXXXXXXXXXXXXX XX XXXXX-XXXX
31 Contact phone 31
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999-999-9999
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49 Want to make your payment online? Find options at www.oregon.gov/dor. 49
50 For more information, see Form OR-19-V Instructions. Make your check, money 50
51 order, or cashier’s check payable to the Oregon Department of Revenue. Write 51
52 “Form OR-19-V,” your daytime phone, the entity’s FEIN, and the tax year on the 52
payment. Don’t mail cash. Mail the payment and voucher to:
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54 Oregon Department of Revenue 54
PO Box 14950
55 Salem OR 97309-0950 55
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57 Enter payment amount 57
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59 150-101-185 59
(Rev. 04-27-23, ver. 03)
60 9999 99 $ , 99,999,999.00, 0 0 60
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63 XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX 63
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